ORIGINAL ARTICLES Experiencein q Hospifql-BosedClinic qs Pqrl ol Chiroproclic UndergroduqleTrqining Hettie Till,M,Sc,,ond GlynnTill,D,C,,F,C,C,S(C), Focultyof Heclth,Technikon Notol An outpotient, chiroproctic clinic wos estoblished ot o provincici hospitoi in South Africo in which senior ^hi,^^,^^+i^ ^+,,!^^+^ r) spent 1 week per month treoting potients. Dotc from the firsifour visilsore described in ur uu1.lrvuru rru\rur this retrospeciive, cross-sectionolstudy, Mostly elderly femoles were seen with c reloiively high proportion of exfremifu
c liso r cle r s
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or unemployed The hisioricollyunderprivilegedeihnic groups benefited most from the initictive,Benefitsond im plic c t io n so f i h e rri i o ti v e o re o d d re s sed,(fhe Journolof C hi roprocti cE ducori on13(1):1-7, 1999 ) K ey wor ds : c h i ro p rc c l c ; e d u c o ti o n ; h o s pi tol s, teochi ng; i nternsni o;nona-edi col
INTRODUCTICN Becausechiropracticclaims to be a primary contact profession, under_eraduate chiropracticeducation hasbeencriticizedbir the medicalfraternityfor, inrer alia, not having anv hospitai-basedexperience,thus denying the chiropracticstudentexposureto a wide range of pathologies(1). This brings into question the competenceof chiropractorsto reiiably make a delinitive diagnosis.or arrive at a list of differentials. Although a review of the types of conditionsseenin chiropracticteachin_e clinics reveaisthat suchconditions arenot restrictedto musculoskeletal ones(2-5), they certainly do not compare to the vast variety of disordersseenin hospitals.Hospital experience, therefore,as pirrt of the chiropracticstudent'seducation, should increasethis competence. In June of 1996. the Faculty of Health at Technrkon Natal, along with health facuitiesfrom other tertiary teachinginstitutionsin the Durban area of South Afnca, were approachedby the Department The Journal of Chiropractic Education CopyrightO 1999the Associationof Chiropractic Colleges Vol. 13 , No. 1 . Pr int edin U. S. A. 1042-5055i$4.00
of Health of the Northern Cape Provinceto help in the supply of health-careservicesto this semiarid. medically underservicedregion. The Departmentof Chiropracticat TechnikonNatai willin_elytook up the challenge. The magnitude of suppiying heaith servicesin tire NorthernCape Provincecan be perceivedr,vhen one realizes that this province covers 32.357col the surfhcearea of South Afnca (363, 389 square kilometers).yet has only l.727o of its population (773,399of -13,820.4214) (6,'7).Roadtransponis not the answerto supply health servicesto small towns separatedbv vast distances:hence a joint venture between the provincial Departmentof Health and the South African Red Cross Ambulance Service was establishedin 1996 in order to develop a Flying Doctor Service.This is also the serviceused to transportthe chiropractic studentsto and from Durban. The needfor chiropracticservicesin the Northern Cape Province had not been formaily established beforethe startof this initiative.However,the prevalence of mechanicallow back pain alone in the lower socioeconomicgroups,the group that mainly uses free clinic services,has been shown to be higher than that in First World communities (8)
The Journal of ChiropracticEducation,Vol. 13, No. 1, 1999
and a recent epidemiologicalstudy reporteda 57Va prevalenceof low back pain in a formal black town_ ship in SouthAfrica (9). Despitethe lack of hospital experienceduring their education,the authoritiesin the Northern Cape Province were satisfiedthat the training received by the studentsat TechnikonNatal rendered senior studentscompetent to screenfor generaldiseases. They could thereforeservea useful role in this medically underservicedprovinceby not only treatingmusculoskeletaldisorders,but in diag_ nosing casesand referring those conditionswhere chiropracticcare is not the therapyof choice. The chiropractic services,whether offered in the hospital, or, as envisagedfor the future, also in the various towns of the province, are given free of chargein order to servethe lessprivilegedmembers of the community. It was decidedto start the ventureby developing a hospital-basedclinic ar the provincial Hospital in Kimberley, some 650 kilometers from Durban, and in February of 1997 the first group of five 6th year students,accompaniedby the deanof the faculty,the head of department,and two staff members(one of them a medical practitionerwho taught diagnostics in the chiropractic program), traveled to Kimberley. The clinic visits were planned to take piace for 1 week every month so that, by the end of the year, most studentsin the 6th year would have had two suchclinic opportunities. The ward supplied in the hospital was curtained off into five cubicles. The only therapeuticequipment used were the five portable adjustingtables and acupunctureneedlesbrought by the students. Treatmentmodalities were consequentlyrestrictedto adjusting,soft-tissuetherapy,and needlingoftrigger points, along with referralsto the hospital's orthotist. Instruction in exerciseprogmms and other life-style modificationswere also given to the patients. One senior nurse and two trainee nurses were on duty. Their functions included sequencingthe patients, obtaining basic demographicdata,ensuring that all supplies neededby the studentswere available, arranging for tests (x-rays, path lab) and referrals, as well as other administrativeneeds. The clinics ran from 08:00 to 18:00 Monday to Friday. Furthermore, during the week, each student had two duties in the Emergency Ward from 20:00 to midnight. This was largely an observationalexperience, although some treatmentswere given. The patients were assessed,a verbal summary presentedto the supervisingclinician, and a diag_ nosis and managementprogram decidedupon, all
Till and Till: Hospital-BasedInternship
in the traditional manner.The records generatedby the studentsbecamepart of the patients' hospita files. Furthermorethe demographicand clinical data servedas a basisfor this studv.
METHODS
This was a retrospective,cross-sectional,descrip_ tive study.The clinics were conductedin February, March, May, and June of 1997. Apil was omiued becauseof overcommitmentof the airplane. Only new patientswho had not previously been seen by students during the survey period were includedin the sample.The patients'files were used to extract date of first consultation,patient's age, gender,race,occupation,and presentingconditions. Frequencytableswere generatedin order to describe the above paramete$.
RESULTS Gender FemalepatientsrepresentedjgTo of the patients comparedto the 2l%o of males, a 3.g:1 ratio. This large difference between the sexeswas observedin all four of the clinic sessions(Table 1). Age The overall valuesfor mean age,median age, and range of agesfor the four clinic sessionswere 53.3, 54.0, and 2-91 years,respectively(Table2). When patientswere categorizedinto age groups,it became evident that the largest percentageof patients in all four clinic sessionswere in the 45-64 group (Fig. 1). Overall, 2.3Voof the patients were younger than 25 years, 23.8Vobetween ages 25 and,44, 53.3Vo between ages 45 and 64, I9.5Vobetween ases 65 and 84, and I.IVo older than 84 years.
Table 1. Gender Distribution (%) Clinic 1 (n: gg) Clinic 2 (n:59) Clinic 3 (n: S5) Clinic 4 (n:49) Total (n :262)
Male
Female
22.2 23.7
77.B 76.3 83.6 79.6 79.0
to.4
20.4 21.0
Table 2. Age at First Presentation(Years) Mean(SD)a Median Range Clinic1 (n:98) Clinic2(n:59) Clinic3(n:55) Clinic4 (n :49) Total (n :261)
54.04(11.73) 55.00 29-87 4e.e7(15.38)48.00 8-91 55.13(15.22)55.00 2-84 53.80(13.48)56.00 23-79 53.30(13.76)54.00 2-91
"SD : standarddeviation. Age of one patientnot recorded.
Roce A total of 83Vo of the patients were from the colored (mixed race) and black racial groups (Fie. 2).
Occupolion of patientsperoccuTable3 showsthepercentage pationcategory. In total,30.27aof the patientswere
pensioners. Unskilledworkers(19.17o),unemployed (12.27a),and housewives(10.77o),were the other significantoccupationgroups.
Clinicol Table4 showsthe distributionof the most prevalent problemsthat presentedin thesefour clinic sessions. Overall, problemsin the lumbar spine (l9.47o) were themostcommon,followedby cervicalspine(l4.4Vo), sacroiliac(I3.9Vo),and thoracicspine(I2.5Vo).After these,disordersin the knee were the most prevalent condition(ll.37o). A summary of the chief presenting conditions indicated that spinal problems representedby far the most common problem (60.2Vo),followed by extremitycomplaints(29.87o)(Table 5). A total of 24 patientswere referred for specialist carc,20 of theseto the Medical OutpatientDepartment (MOPD) and four to the Surgical Outpatient Department(SOPD)(Table6). Of the 20 patientsthat
A GE GROUPPROPORTION
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lrct-lxtczl itrcLINcal al i n cr-rrrrrc
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66-84
Figure I
The Journal of Chiropractic Education,Vol. 13, No. '1, 1999
RACEDISTRIBUTION WHITE 12%
Figure 2
Table3. Occupations(%) Clinic1 Pensioner Unemployed Nurse Housewife Unskilled Teacher Professional Clerical Other Unrecorded
Clinic2
25.3 11.1 10.1 23.2 3.0 1.0
Clinic3
Clinic4
28.8 10.2 '13.6
36.4 12.7
8.5 18.6 0 3.4
10.9 21.8 trtr
34.7 28.6 2.0 14.3 8.2 o 2.0 6.'1 4.1 0
c. l
3.0
6.8
tJ.z
Number
Percentage
58 81 cz
13.9 19.4 12.5
OU
1A A ta.a
24 4
6R
1.2 1.0 t.I
2 20 47 9 11 36 I I
n : 417 Till and Till: Hospital-BasedInternship
t.o
0 | .tt J.O
Table4. Ghief PresentingConditions(%) Sacroiliac Lumbarspine Thoracicspine Cervicalspine Head Shoulder Elbow Wrist Hand Hip Knee Ankle Foot Visceral Uncertain
55
0.5 4.8 11.3 2.2 z.o 8.6
0.2
Total
30.2 12.2 8.8 10.7 ' 1 9 .1 2.3 '1.9 3.4 3.8 7.6
were referred to the MOPD, five were for gynecological investigation,four for hypertension,three for cardiacinvestigation,one for liver investigation,one for possible nephritis, one for rheumatoid arthritis, four for abdominalpain, and one for cellulitis of the foot. The four patientswho werereferredto the SOPD were all for the investigationof breastlumps.
Table 5. Distributionof Chief Gondition(%) Percentage Spinal Head Extremity Visceral Uncertain
60.2 1.2 29.8 8.6 0.2
Table 6. Referrals To MOPD Clinic1 (n :99) Clinic2 (n : 59) Clinic3 (n :55) Clinic4 (n : 49) Total (n:262)
To SOPD
Number
Percentage 5.1 6.8 t4.c
14.3
20
24
9.2
MOPD,MedicalOutpatientDepartment;SOPD,SurgicalOutpatientDepaftment.
DISCUSSION The gradual reduction in new patients in each succeeding visit was due mainly to the fact that an ever-increasingnumber of repeat patients were being seen. Another reason was that the plane's schedulesometimesmeantleaving earlier on Friday, thus shorteningthe last day of the visit. The large differenceobservedin the total numbers of female patients(797o)comparedto males (ZlVo) differs from most other published studies on the provision of chiropractic care in teaching clinics (2-5). Most studies of chiropractic patients have shown a fairly even gender distribution, slightly favoring females in some instances.For example, in Australia (5), it was found that slightly more female patients (52.67a)attendedteaching clinics, while slightly more male patients(5I.8Vo) attended private clinics. An initiative providing chiropractic care to the underprivilegedin Melbourne, Australia (10) indicateda 547ofemale patient population' A study evaluating 15,114patientspresentingat the CanadianMemorial ChiropracticCollege (CMCC) over a 5-year period (2) found that approximately equal numbers of males and females attended the clinics. The only results similar to this study were found in a report on an elective in the undergraduate medical curriculum at the University of Louisville in the United States where undergraduatemedical studentsprovide care to a medically underserviced community (11). A total of 664 office visits were recordedat the communityclinic and of thosevisits, every 10th patient encounter(up to a total of 60 charts) was selectedfor inclusion in the study. Of the 60 chartsselected,52were locatedand indicated that 807aof the patientswere female and207o male. The large difference between males and females recordedin Kimberley is not normal for that province
as, accordingto data publishedin the South Africa Survey 199611997,there are only slightly more femalesthan malesin South Africa, with the proportions in the Northern Cape Province being 50.3Vo femalesto 49.7Vomales (7). Although the rangeof agesof the patientsincluded in the Kimberiey study (2-91 years) is similar to the 1-93 range reported in the CMCC study (2), the mean age of the patientsin this study was 53.3 as opposedto the 32.5 years for male and 33.4 years for female patients as found at the CMCC teaching clinics. The mean age in the Melbourne community project (10) was 39, and that of patients seen in Australianteachingclinics (5) was 34.4' Possible reasonsfor this geat disparity in the averageagesof the Kimberley patientscomparedto the other studies could include: 1. Hospitals that do not charge or charge very little for their services could be expected to atffactpensionerswho would want to protecttheir income. 2. Intems at college teachingclinics may persuade their young friends and family members to becomepatientsof theirs in order for the intern to meet his or her clinic requirements' The mean age of patients seen at chiropractic teachingclinics generallyrangesfrom about 33 to 43 years (2-5). The fact that the Kimberley clinic catered to a much older age group is also not consistentwith the populationfiguresin the Northern Cape Provincewhich, similar to the rest of South Africa, has a very young populationwith only 6.17o being over 64 years(7). A variablenot normally includedin other studies of this ltind is racial distribution of patients seen. In South Africa, the political legaciesof the past have resultedin an imbalancein the provision of
The Journal of Chiropractic Education, Vol. 13' No. 1' 1999
servicesbetweendifferent groupsand betweenurban and rural populations,and in this contextdistribution by race group is therefore an imporlant indicator of healthandthe provisionofhealth services.The racial breakdown of the population in the Northern Cape Province is 3I.73Vo African (black), 0.237o Asian (indian), 52.077ocolored (mixed race),and l5.9j%a white (7). The two major race groups (black and coloured)make up a total of 83.8Vawhich matches the 83Vaof these two groups seenin the Kimberley clinic (Fig. 1). In this regardthe chiropracticservice achievedan importantpurpose,in that the black and colored groups,historically the most disadvantaged in SouthAtrica, benefltedthe most. A disproportionatelyhigh percentage(42.4Va)of the patientswere either pensionersor unemployed, which would account for nearly half the patients being over 55 years old. As mentionedpreviously, this is possibly due to the treatmentbeing free of charge.Another possiblereasonis that, as they had no employmentresponsibilities,they could readily spendseveralhours waiting to be attendedto. Even when compared to the high unemployment rate of patients in one srudy (3) (a mean of 32Vo in the six clinics), the Kimberley figure is still high, while other teaching clinics had much lower rates (8Vo-9.47a)of unemployedor retired patients(2,5). Although not stated,presumablyall of the patientsin the Melbourne community project (10) were unemployed. If this was so, it is interestingto note that their averageage was only 39. "Nonmanual" occupationsin the Australian teaching clinics (5) constituted54.4Voof all patients,at CMCC aboutJ4%o(2), in the United Statesa meanof 637aof all employedpatients(3), and in Kimberley about 31Vo of all patients. "Manual" occupations comprisedabout197oin Kimberley,3SVoin Australia (5), a mean of 377oof employedparientsin the United States(3), and about 777oin Canada(2).
The categoriesin Table 4 representthe areas of chief complaint only. Areas of referred or radicular pain are not reflectedin this list. For example,a facet syndromeof the right lumbosacraljoint with pain referred to the right posteriolareralthigh will be recordedunder "lumbar spine" only. The only exception would be, for example, pain felt only in the lumbar spine, but due to a thoracolumbar syndrome;suchwas includedunder..thoracicspine.', All disorderswere recorded, hence any one person may have had multiple diagnoses. Table7 is a comparisonof conditions seen in chiropractic teaching environmentsin four different countries.One interestingcompansonis the lower rate of spinal disorders in Kimberley, due almost exclusivelyto the relative paucity of cervical spine complaints(14.4Vo),comparedto a mean 26.5Voof the other three. The other area of relatively poor representationin Kimberley was that of headaches (l.2%o), compared to a mean of about 5.4Va in the others. On the other hand, extremity disorders occurredat almost double the rate in the other coun_ ties (29.9Vacomparedto a mean of 17.82o).This was due largely to a high rare of hip (4.gVo) and knee(11.37o)disorders,probablyassociated with the patients' ages,the fact that most were female, and many were overweight. Possiblebenefitsflowing from this hospitalexperi_ ence,evenafteronly fourvisits,includethefollowing: o The studentsgained clinical experienceunlikely to be had in the on-campusteachingclinic. o As the 6th year is designed,in paft, to bridge the highly supervised,time-consumingintemship experienceof the 5th year, to the faster pace of the "real world" of private practice, the opponu_ nity ofpracticing underpressureby havingqueues of patients waiting (with the benefit of an experi_ encedclinician present)was an addedadvantase.
Table7. comparisonof conditions seen in Four countries (%) Australia (5)
Canada (2)
USA (3)
Kimberley, South Africa
73.2
78.0 10.0 24.4 11.2 32.4 ? 18.8 3.2
72.2 ?
60.2 13.9 19.4 12.5 14.4 1.2 29.9 8.6
Spinal Sacroiliac Lumbar Thoracic Cervical Head Extremity Other
Till and Till: Hospital-BasedInternship
3g.2 16.5 23.6 8.1 15.8 10.5
oo.u 12.7
23.5 2.7 18.8 7.0
The studentswere exposedto the sociology of a hospital by, for example,learning to interact with nursesand use the hospital'sreferralsvstem. r The students leamed to use the "blank page" approachto casetaking. Nursing and medical staff developeda more accurate understandingof and respectful attitude to chiropractic. Studentsgainedconfidencein working in a medical environment. The staff gained experienceand confidence too, as, with the exceptionof one, none of them had had such an experiencepreviously. o Members of the public never previouslyexposed to chiropractic, and unlikely ever to have been, being of the lowest socioeconomicgroup,learned of and benefitedfrom chiropractic; even for those who could afford the services, there was not a single chiropractor in the entire Northern Cape Province. o The public relationsbenefit for the professionand for Technikon Natal should be enormous. o The Department of Health of the Northern Cape Provincehas,asa resultof this experience, created a full-tirne post in this state hospital for a chiropractor. The authors are aware that the above statements are subjectiveand need verification in further studies.
CONCLUSION This study describedthe first four visits of senior chiropractic students to a provincial hospital. The patient population was not representativeof that found in the province,yet the exercisedid address, in part, some of the historical political disparities peculiar to South Africa. It must be rememberedthat these visits to the hospital constitutea small, yet, we believe, significant component of the students'professional(as opposedto purely clinical) experience,and occur in the year after they have completedtheir internship. A study of the types of conditions seenduring their year of internship will help complete the picture in terms of their educationand training. Although the exposureof the studentsin this study has not been to the full range of disorders to be seen at the Kimberley Hospital, it is a move in the right direction. We are hopeful that in South
Africa chiropracticeducationwill, in the near future, incorporate such exposure at even earlier levels of the educationalprocess.
ACKNOWLEDGMENTS Specialthanksto Dr. M. F. Matlaopane,Minister of EnvironmentalAffairs. WelfareandHealth.andDr. B. Kistnasamy,DeputyDirector-General,Departmentof EnvironmentalAffairs, Welfare andHealth. Northern CapeProvince,SouthAfrica, and the staff of that departmentaswell asthe staffof theKimberley Hospital, for makingthe whole initiativepossible. Received,November15, 1997 Revised,January23, 1998 Accepted,November3, 1998 Reprint requests:HettieTill, P.O.Box 953,Durban, SouthAfrica 4000.E-maii:
[email protected]
REFERENCES 1. Ingiis BD, Fraser B, Penfold BR. Chiropracric in New Zealand. Wellin gton : PD Hasselberg, 19'79 :235 . 2. Waalen DP, White TP, Waalen JK. Demographic and clinical characteristics of chiropractic patients: a five year study of patients treated at the Canadian Memorial Chiropractic College. JCCA 1994;38(2):15-82. 3. Nyiendo J, Phillips RB, Meeker WC, Konsler G, Jansen R, Menon M. A comparison of patients and patient complaints at six chiropractic college teaching clinics. J Manipulative Physiol Ther 1989;12(2):79-85. 4. Sawyer CE, Ramlow J. Attitudes of chiropracticpatients: a preliminary survey of patients receiving care tn a chiropractic teachingclinic. J Manipulative Physiol Ther -163. 1984:7(13):1.57 5. Walsh MJ. A study of patients and patient complaints at chiropractic teaching clinics. Chiropr J Aust 1992; 22(2):61-64. 6. Mclntyre D, Bloom G, Doherty J, Brijlal P. Health Expenditure and Finance in South Africa. Durban: World Bank and Health SystemsTrust, 1995:3-20. 7. Sidiropoulos E, Jeffery A, Mackay S, Forgey H, Chipps C, Corrigan T. South Africa Survey 199611997. Johannesburg:South African Institute of Race Relations, 1997:2-54. 8. Nagi SZ, Riley LE, Newby LG. A social epidemiology of back pain in general population. J Chron Dis 1973; 26:769-7'79. 9. Van der Meulen AG. An epidemiologicalinvestigationof low back pain in a formal black South African township. M. Tech. dissertation,Technikon Natal, Durban, 1997. 10. Ellis WB, Long CJ. Mission impossible: providing chiropractic for the peopie of the streets. Chiropr J Aust 1992122(l):24. 11. Quinby PM, Papp KK, Kirchinger S. Student involvement in the care of the underserved. Medical Teacher 1997;19(2):129-132.
The Journal of Chiropractic Education, Vol. 13, No. 1, 1999
